Countering the Cruel Tutelage of Healthcare Access, Quality and Cost: How mHealth Can Do It Faster, Better and Cheaper

While there many maxims about the delivery of healthcare, the MedSolis Chief Medical Officer PHB has discovered that three in particular stand out:

1) Many healthcare outcomes are more a function of social, economic and cultural determinants than medical quality. Zip code trumps diagnosis code.

2) Say's Law warns us that healthcare utilization may be a function of  sevice availability rather than need. As a result, compelling innovations like this or this can be "additive" to healthcare, not "substitutive." Demand trumps discovery.

3) Healthcare access, quality and cost are interdependent, and improvements in one has downsides in the other two.  For example, price controls can lead to lower access in the form of queues. Increasing quality can drive up prices.  And, Obama's healthcare reform emphasizing better access arguably led to higher prices.  

 

Trump's rhetoric trumps brainy Obamacare.

Naturally, there are exceptions to every rule.  And the PHB wonders if healthcare technology's mHealth may offer an important exception to rule number three.

If so, there are important implications for U.S. healthcare delivery.

An important mHealth mantra for MedSolis is "faster, better, cheaper."  mHealth is defined as as any medical practice supported by devices such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless technology. A considerable body of literature on the topic shows that patients using mHealth can access the information they need to make informed choices, that those informed choices serve greater engagement, and that this leads to fewer avoidable complications.

Examples from the MedSolis #mHealth archives:

Mary Jones* has diabetes, and uses her smart phone paired bluetooth-enabled blood sugar monitor to assess her diabetes control versus diet, exercise levels and medications. Her A1c improves, which correlates with her future health care costs.  She not only sees her outpatient physicians less often, but the A1c data inform public measures of quality and decreases the likelihood of depression.  Ms. Jones has hit the trifecta: lower cost, higher quality and better access to more care.

William Smith* has heart failure and has just been discharged from a hospital. He uses a telemonitoring-linked home scale to detect the subtle increases in weight from fluid retention that can herald an exacerbation of his condution.  William knows how to increase the dose of some of his medicines leading to return of his weight to normal. William has avoided an unnecessary night in the emergency room.  What's more, the avoided readmission is an important measure of quality. Mr. Smith has also hit the trifecta of lower cost, higher quality and better access to more care.

Bottom line: as healthcare consumes a greater fraction of the U.S. gross domestic product, the cruel tutelage** of healthcare acess-cost-quality can be mitigated by faster-better-cheaper.  Whether it's Obamacare, Repeal, Replace or Trumpcare, the the value proposition of mHealth will endure.

*Names and scenarios are realistic, but ultimately fictional

** With apologies to Pai Mei and his fans

Additive, Not Substitutive, Health Care Innovation

Sirens calling the unsuspecting
to their doom

If, like many of our policy and political elite, you have also been seduced by the siren call of health care "innovation" as a cost-saving panacea for the United States, you may want to check out this JAMA Viewpoint.

"Transcatheter aortic valve replacement" (TAVR) was supposed to be a less invasive and presumably safer and cheaper alternative to open heart surgery or "surgical aortic valve replacement."  Prospective clinical research trials demonstrated that TAVR was an option for small numbers of persons who may be too frail to tolerate open heart surgery.  Academics and regulators anticipated that TAVR use would be limited to carefully selected patients cared for at high-end "center of excellence" hospitals. 

That's not what happened in the Philadelphia region. Large and small hospitals that were only blocks apart followed the money and quickly established TAVR programs.

New York City turned out to be different.  Since health systems in Manhattan seem to have a higher degree of "integration," the authors wonder if TAVR was functionally rationed.  In addition, New York apparently has an aggressive "certificate of need" program for new technology.

True to their academic pedigree, the authors advocate for 1) further research trials to better define the risks and benefits, 2) the creation of TAVR registry databases that are populated by long-term outcomes, 3) the participation of "expert panels" that can opine on the best use of this technology, 4) "safe harbor" regulations that promote centers of excellence and 5) helping physicians do a better job of educating patients about the risks vs. the benefits.

Based on its limited knowledge, the Population Health Blog has a different take:

1) New technology is a genie that cannot be bottled. If it offers patients a new treatment option in an unfettered market, it will be rapidly adopted.  The impact is not substitutive, but additive.  It's Say's Law, turbocharged with Medicare financing and paid for by the U.S. taxpayer.

2) The PHB isn't sure "integration" played much of a role in New York City's slow uptake, since the Philadelphia region is likewise dominated by regional "integrated systems."  More likely was the top-down regulation imposed by certificate of need.  Other top-down approaches include utilization management.

3) Research, registries, panels, safe harbors and physician education are about as likely to stem the demand for TAVR as much as nicely asking 24's Jack Bauer to stop being so mean.